Health History Form ADA American Dental Association®

Health History Form

[Email:

Today's Date:

ADA American Dental Association?

America's leading advocate for oral health

J

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be? additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Name:

Lost

First

Address:

Moiling address Occupation:

Middle

Home Phone: Include area cade City:

Height:

Weight:

Business/Cell Phone: Include area cade

(

)

State:

Zip:

Date of Birth:

Sex: M

SSII or Patient 10:

Emergency Contact:

Relationship:

f-.- -

-

-

- ..-.-.-.

If you are completing this form for anolher person, what is your relationship to that person?

.. -.--.---...

I

Home Phone: Include area cade

Cell Phone: Include area cade

~Your Name ..--.-- ..-

-.-- ..-

__ _ __ _. __ ._._ .. .. .._._._

_---_._

Do you have any of the following diseases or problems:

__ __ __ __ _ _R-e-la_tionsh..ip_ ..

._._._

..

_._ -_

_--.-_._----

(Check OK if you Don't Know the answer to the the question)

Yes No OK

Active Tuberculosis ..

000

Persistent cough greater than a 3 week duration

.

000

Cough that produces blood........

.

..

000

Been exposed to anyone with tuberculosis

.

Ifyou answer yes to any of the 4 items above, please stop and return this form to the receptionist.

000

Dental Information

For the following questions, please mark (X) your responses to the fallowing questions

Yes No OK

Yes No OK

Do your gums bleed when you brush or floss?.

.

Are your teeth sensitive to cold, hot, sweets or pressure? .

.

Is your mouth dry?.

.

Have you had any periodontal (gum) treatments?.

Have you ever had orthodontic (braces) treatment?

Have you had any problems associated with previous dental treatment? ..

Is your home water supply fluoridated?

Do you drink bottled or filtered water?

..

If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY

000 000 00 0 .. 0 0 0 00 0 .0 0 0 .. 0 0 0 000

i Do you have earaches or neck pains? ........... .. ................ . ....

............ 0 0 0

Do you have any clicking, popping or discomfort in the jaw? . ..... ............... 0 0 0

Do you brux or grind your teeth? ..................................

........... 0 0 0

Do you have sores or ulcers in your mouth?.

.................... 000

Do you wear dentures or partials?..........

. .. ...... .............

000

Do you participate in active recreational activities? ....

.....................0..0..0....

Have you ever had a serious injury to your head or mouth?................

o .... 0

0

i Date of your last dental exam:

What was done at that time?

Are you currently experiencing dental pain or discomfort? .... ...... 0 0 0

Date of last dental x-rays:

What is the reason for your dental visit today?

How do you feel about your smile?

M e die a I Infor mat ion Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

Are you now under the care of a physician? Physician Name:

Address/City/State/Zip:

Yes No OK 000 Phone: Include area cade

Have you had a serious illness, operation or been hospitalized in the past 5years?

or problem?

, !

..... .. __.. __

_.

._

. __ _

Are you in good health? .

__ _ _ __ Has there been any change in your general health within the past year?

_. .. -.-

_ .._-_.

_

_-_ .. _ .. _.

If yes, what condition is being treated?

_..__ J!;:~~~t~~i:~u%::::~~c~::~~~tIYtak~~a~Ypr~scriptlon................

000

000

.

i If so, please list all, including ~i and/or dietary supplements:

!

vitamins,

natural or herbal preparations

Date of last physical exam:

? 2012 American Dental Association Form5S00

Yes No OK 000

~ 00 _

Me d ica I Info r mat ion Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

(Check OK if you Don't Know the answer to the question)

Do you wear contact lenses?.

Joint Repl~~~;:;:;;~Ht~~- ~~h-~;d~-~~~-;-;th.;t.p~~t~dilj~;i;:;-.t-.--.-.- -

Yes No OK I

000

iI Do you use controlled substances (drugs)?

..T Do you ~;;t;;-ba~~~(smokin~-;;~fTchew,

bidis) ?~..

--:-?~-? ..-~~--~:-

(hip, knee, elbow, finger) replacement?

Date:

If Yes, have You had anY com Plications?

Are you taking or scheduled to begin taking an antiresorptive agent

000

I If so, how interested are you in stopping?

{ I Circle one: VERY / SOMEWHAT / NOT INTERESTED m..mmmmmmm

, Do you drink alcoholic beverages?..............................

(like Fosamax?, Actonel?, Atelvia, Boniva", Reclast, Prolia) for

osteoporosis or Paget's disease? ..

..

.. ..mmm__..

...

...

.

?mmm

.. m .. m_m

Since 2001, were you treated or are you presently

scheduled

to begin

mmm

0

.. mmmm

00

....-

iIlf yes, how much alcohol did you drink in the last 24 hours? If yes, how much do you typically drink ina week?

Imr:;:

?

WOMEN ONLY Are you:',

Yes No OK 000

DDD

000 _

~:~a:::n~a~~~~;~ear::il~~~~~~:::~:~:1

~~~~I~~~~~~~~~:~~:i~9x:r~~A)

Paget's disease, multiple myeloma or metastatic cancer?

Date Treatment began:

000

. ~reg~ant?f"k"""""""

l' ukm e~Otteets. -I-?-II--h----I-

I?

a mg Ir con ro pi s or ormona rep acement

Nursing?

000

000 ..

..

000

Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction. Local anesthetics Aspirin Penicillin or other antibiotics Barbiturates, sedatives, or sleeping pills Sulfa drugs Codeine or other narcotics

Yes No OK

_ ODD _ ODD _ ODD _ ODD _ ODD _ ODD

Metals Latex (rubber) Iodine Hay fever/seasonal Animals Food Other

Yes No OK

ODD ODD ODD ODD ODD ODD ODD

Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.

I--

.. .__ .

Artificial (prosthetic) heart valve......

m

..

Yes ~~_[)~ ...,

. 000

Autoimmune disease ..

Previous infective endocarditis.

000

Rheumatoid arthritis ..

Damaged valves in transplanted heart

.

Congenital heart disease (CHD)

Unrepaired, cyanotic CHD..

Repaired (completely) in last 6 months

Repaired CHD with residual defects...........

. 000

000 000 000

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other farm of CHD.

Cardiovascular disease .. Angina .. Arteriosclerosis .. Congestive heart failure ... Damaged heart valves. Heart attack .. Heart murmur Low blood pressure .. High blood pressure Other congenital heart defects ..

Yes No OK

ODD ODD ODD ODD ODD ODD . ODD ODD ODD

ODD

Mitral valve prolapse .. Pacemaker .. Rheumatic fever .. Rheumatic heart disease .. Abnormal bleeding .. Anemia Blood transfusion

If yes, date: Hemophilia AIDS or HIV infection Arthritis ..

Yes NoOK

ODD ODD ODD ODD ODD . ODD

. 000 _

. ODD ODD ODD

Systemic lupus erythematosus .........

Asthma........

...

Bronchitis ...

Emphysema.

Sinus trouble ..

Tuberculosis ..

Cancer /Chemotherapy/ Radiation Treatment.

Chest pain upon exertion ..

Chronic pain, ..

Diabetes Type I or II ..

Eating disorder......

......

Malnutrition ..

Gastrointestinal disease ..

G.E. Reflux/persistent heartburn ..

Ulcers ..

Thyroid problems ..

Stroke ..

Yes No OK 000 000

000 000 000 000 000 000

000 000 000 000 000 000 000

000 000 000 000

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? ......

_ ????????????

mom.m

???? _

? m_._.

Name of physician or dentist making recommendation:

.... .... .. ....... ...

Glaucoma .. Hepatitis, jaundice or liver disease .. Epilepsy .. Fainting spells or seizures .. Neurological disorders.

If yes, specify:

Yes No OK

o0 0

o0 0 o0 0 o0 0 o0 0

Sleep disorder ...... Do you snore?. Mental health disorders ..

Specify:

o0 0 o0 0 o0 0

Recurrent Infections .. Type of infection:

o0 0

Kidney problems Night sweats. Osteoporosis .. Persistent swollen glands in neck .. Severe headaches/ migraines .. Severe or rapid weight loss .. Sexually transmitted disease .. Excessive urination.

o0 0

ODD

o0 0

o0 0

o0 0 o0 0 o0 0 o0 0

Phone: Include area code

---

ODD

Do you have any disease, condition, or prob'lem;:;ot'li~t~d above that yo~ tfii;:;k'i"~ho~jd know about?'''''''''-Please explain:

.. m

.. ....mm

.. mm...

......

u

?mmm

.. mm

.. mm

.?

m_

ODD

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Signature of

Guardian:

Date:

~nature of Dentist:

Date:

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